Some links and readings posted by Gary B. Rollman, Emeritus Professor of Psychology, University of Western Ontario

Tuesday, December 25, 2012

Approaching Illness as a Team at the Cleveland Clinic - NYTimes.com

The Cleveland Clinic, long considered a premier medical system, is gaining new renown for innovation in improving the quality of care while holding down costs.

In its most fundamental reform, the clinic in the past five years has created 18 "institutes" that use multidisciplinary teams to treat diseases or problems involving a particular organ system, say the heart or the brain, instead of having patients bounce from one specialist to another on their own.

The Neurological Institute, for example, provides both inpatient or outpatient care for those with strokes and brain tumors, as well as those with epilepsy, multiple sclerosis, depression and sleep disorders, among other conditions.

On a recent visit, we observed one such team, consisting of a neurosurgeon, a neurologist, a neuroradiologist, a neurologist with advanced training in intensive care, a physical and rehabilitation doctor, a medical resident, a physical therapist and a nurse. As they made rounds from patient to patient, they had a portable computer that displayed electronic medical records so that the whole team could see how the patient was doing and plan the course of care for the day.

This team approach can improve the quality of care because all the experts are involved in deciding the best treatment option, which can save time and money. The neurological team, by consensus, has been better able to determine which acute stroke patientsneed a risky and expensive treatment that involves threading a catheter through an artery in the leg up into the brain to destroy a clot. It cut the use of that treatment in half, reducing costs and deaths and improving outcomes.

The Cleveland Clinic has strong leverage to drive such reforms because its staff physicians are salaried and are granted only one-year contracts and subjected to annual performance reviews. Those reviews apply measures of quality, like patient improvement, patient satisfaction and cost reductions. It raises the pay of those who get high marks, reduces the pay of poor performers and even terminates some doctors who fall short. This approach could become more widespread as more hospitals and doctors move toward the salary-based model.

Data analysis to evaluate how well treatments work is also a big part of the medical practice. For instance, the clinic analyzed outcomes for heart surgery patients and found that those who had received blood transfusions during surgery had higher complication rates afterward and a lower long-term survival rate. As a result, it has adopted strict guidelines that limit the use of transfusions.

Such judgments about a treatment's effectiveness are made by doctors, not by financial administrators, so they tend to be accepted. One analysis found that suturing could be done as well with a $5 silk stitch as with a $400 staple, leading to a big drop in the use of the staples. At the same time, the clinic has also carried out simpler reforms, like improving sterile conditions, which has reduced catheter-related bloodstream infections by more than 40 percent and urinary tract infections by 50 percent. All this has happened in a remarkably short time. Patients seem to like the treatment they get. A federal government survey of patient opinion last fall found that 80 percent of the patients gave the Cleveland Clinic a high rating over all and 84 percent would recommend it to others, well above the state and national averages in the 69 percent to 71 percent range.

Still, many patients are clearly unhappy. A series this year about confusing medical bills and unexpectedly high charges by The Plain Dealer of Cleveland elicited hundreds of patients' complaints mostly directed against the clinic, because it had reclassified off-campus physician practices and health centers as hospital outpatient facilities and tacked on a "facility fee" for services previously billed at lower doctor's office rates. The clinic says the added fees are justified because it provides better quality controls and health information technologies in its outpatient units than that available in a typical doctor's office.

Medicare's spending per patient at the clinic for an episode of illness that requires hospitalization is below the national median, suggesting that the clinic's cost-cutting efforts are working. The University HealthSystem Consortium, an alliance of the nation's leading nonprofit academic medical centers and teaching hospitals, gave the clinic one of its "rising star" awards in September for significant improvements over the previous year in quality, patient safety and clinical effectiveness, an indication that its quality efforts are taking hold.

The Cleveland Clinic's progress in restructuring itself, said Michael Porter, a Harvard professor who analyzes health care delivery and organizational change, is "light speed" compared with other institutions. The clinic is "a model of where we need to go," he said, "Not perfect, not done, but far along."